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Ple a s e no t e:

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1

Opportunities for radiographer reporting in Ghana and the potential for improved patient

care

Abstract

Objective: To explore factors that influence the introduction of role extension in

radiography and to discuss its potential for improved healthcare in Ghana.

Key findings: Key findings of this review are the lack of literature on role extension in

radiography in Ghana. The factors that have influenced the introduction of role extension in

radiography globally include a shortage of radiologists, increased demand for radiology

services, government policy and radiographer's desire for professional development.

Conclusions: Evidence indicates that radiographers can report radiographs as accurately as

radiologists and appropriate education improves their performance. Radiographer-led

reporting is the professional practise most likely to deliver local patient benefit.

Developments in professional perceptions, training, education and regulation of reporting

are required to establish confidence in radiography-led reporting.

Implications for practice: Radiographer reporting has the potential to improve patient

outcomes, reduce waiting times, increase job satisfaction for radiographers and result in

financial savings.

Introduction

Extended working is the post-qualification acquisition of skills or activities that extend

healthcare practices by working across professional boundaries.1,2 The terms role extension

and advanced practice are sometimes used interchangeably, but it is instructive to consider

them as describing distinct roles: the former being to perform a task, such as image

reporting, to a skilled level;3 the latter signifying a broader set of professional activities ,

likely to influence wider care pathways.4

There are examples of extended roles in nursing and some allied health professions from

the US, Canada, UK, and Australia, all of which have advanced nurse practitioner roles and,

for example, the assistant radiologist role in the US. Established drivers for extended roles in

radiography are an increased imaging workload and shortage of radiologists, coupled with

advances in health system technologies and professional aspirations of radiographers.6- 8

Sustained implementation of extended radiography roles in the UK9 and other developed

2

countries10-14 has demonstrated latent benefits to healthcare in terms of reduced patient

waiting times, reduced healthcare costs, enhanced job satisfaction for practitioners and

increased accuracy of reports.7,15-26 Despite such benefits, professional divisions endure

between radiography and radiology regarding the appropriate scope of practices.15-17,27

Developing countries share the generic workload drivers for role extension, but face

additional resources constraints28 and a particular historical development of professional

power hierarchies or political/social systems that favour the status quo.29 This paper

evaluates role extension opportunities for diagnostic radiography in Ghana with a focus on

image reporting: contexts to this discussion paper being stark deficiencies in radiologist

coverage, a substantive backlog of unreported radiographs and the potential for a positive

impact from radiographer reporting on societal health in Ghana. Evidence, primarily from

the UK, is used to inform a model of radiographer reporting in low resource settings. The UK

experience is relevant as Ghana inherited many NHS structures and practices through

colonial legacy.

The Ghanaian health system

The Ministry of Health (MoH) formulate policy and provide strategic direction for national

healthcare delivery. MoH policies are implemented by the Ghana Health Service (GHS),

which is responsible for all health facilities except private, teaching and mission hospitals.30

The not-for-profit faith-based hospitals, and the few private hospitals, accept the MoH

National Health Insurance Scheme. The hierarchy of GHS provision is from national

headquarters to regional health directorates/hospitals, district health directorates/hospitals

and finally to local polyclinics.30 Nine of the 10 regional hospitals are equipped with modern

digital X-ray machines and a CT scanner. Each of Ghana’s 216 district hospitals has a

radiology unit including (at least) a general- purpose x-ray unit and ultrasound machine.

However, a shortage of radiologists and lack of contingency planning has meant that the

MoH has had to train radiographers and midwives in the district hospitals in obstetric

ultrasound. This training was implemented in an ad hoc way without a strategic policy.

Radiologist provision

Ghana has a population of about 25 million.31 However, in 2014, there were only 35

radiologists in the country.31,32 Select workforce comparators are provided in Table 1.

3

Despite the number of UK radiologists being considered inadequate33 it is approximately 70

times the number of radiologists-per-head of Ghanaian population.

Country Population

(million)

Number of radiologists

/100,000 population

Number radiographers

/100,000 population

Ghana 25 0.14 1.2

Kenya 43 0.47 2.4

UK 60 7 43.3

Greece 11 30 Not available

EU average 19 12 43.9

Table 1 Comparison of radiologist/radiographer to population ratio in Africa and Europe.31-37

The national shortage of radiologists is exacerbated by their uneven distribution across the

administrative regions of Ghana (Fig 1).32 For example, the Northern region accounts for

30% of the total land mass and 10% of the national population,38 but currently has only two

visiting radiologists.32 Most radiologists are located in the southern capital Accra and in the

second city of Kumasi. The skewed distribution of radiologists is compounded for service

users by the fact that those regions ill-served by radiologists also have the fewest doctors.

For example, the doctor-to-population ratio in greater Accra region in 2015 was 1:7,196,

whilst the figure for Upper East region was 1: 30,601.39

A net effect of gaps and inequalities in access to radiology services are many unreported

radiographs and overburdened doctors with inadequate training to interpret images.

Figures are not currently available, but in the (lead) author’s wide clinical experience in

Ghana, a majority of all radiographs remain unreported with high rates in regions with low

doctor-to-patient ratios. The MoH does not currently have a strategy to address the

radiologist shortage. The cost to the GHS of employing a senior radiographer is

approximately £4000 per annum compared to at least £8,500 for a radiologist.40 The

number of unreported radiographs combined with health economic considerations suggest

that Ghana is ripe for an evaluation of radiographer reporting, including the extent to which

the political will and other required conditions exist.

Radiography in Ghana

4

The first radiology unit was established in the Korle Bu teaching hospital in 1929 by the

colonial Governor responsible for the Gold Coast.41 This was principally in response to a

nationwide outbreak of tuberculosis amongst workers in the lucrative mining industry.41 The

service then relied upon nurses with a few weeks training to operate radiographic

equipment. Now radiography is a degree-level profession with a developing Society of

Radiographers (GSR) and a new regulatory body of allied health professions (AHPC).41 Key

educational milestones include: the MoH establishing a school of radiography in 1951;

adoption of a modified UK diploma curriculum whilst a UK trained radiographer (Mrs

Harriet Dua) was principal; the conversion to University of Ghana status with a bachelor’s

degree award in 2002 and postgraduate programmes from 2006.41 In the context of

proposing changes to professional boundaries, it is notable that the introduction of a degree

programme in Ghana did not meet the same resistance that was seen from the UK DoH and

professional stakeholders.41,42 This was largely due to justification provided by the previous

UK experience.

There are currently 300 registered radiographers practicing in Ghana43 compared to more

than 26,000 radiographers registered with the HCPC in the UK (Table 1).44 In a historical

parallel to 1929, the MoH has recently commissioned 52 modern digital x-ray units for

installation at district hospitals as part of the national tuberculosis control program.45

Resource constraints require locally appropriate and innovative approaches to role

extension in radiography to match the investment in equipment. We propose a phased

approach to role extension by advocating for the initial adoption of radiographer reporting,

where the potential impact on access to healthcare is likely to be greatest.

Methods

This discussion paper explores opportunities for radiographer reporting in Ghana and its

potential for improved patient care. Relevant literature was identified using a structured

search approach. Google Scholar was used to establish current contextual data about the

healthcare sector in Ghana and to conduct a scoping search of international literature on

role extension in radiography. A comprehensive search of relevant literature was then

conducted via Cumulative Index for Nursing and Allied Health Literature (CINAHL) and

Medline via Ovid databases and the Radiography journal, as a key professional forum.

Keywords used in combination were radiography, radiographer (and international variants

5

radiologic technologist, x-ray technician, medical radiation technologist, radiologist

assistant); role extension (and related terms extended scope of practice, role development,

advanced practice, skill mix, non-medical consultants, radiographer reporting and red dot).

The search was not limited by date so as to include key historical papers. No geographical

limit was applied to include literature from developing countries, however, papers not

written in English were excluded. Inclusion criteria were articles that focused on/including

the radiographer reporting aspect of role extension with unrestricted accessibility to the full

text. Relevant health policy papers were also sought from UK and Ghanaian governments.

Most of the located literature originated from the UK. No empirical papers or opinion pieces

were found on role extension in radiography from Ghana. The only African literature was

from South Africa and Nigeria. Although a much larger country, Nigeria provides a close

geographic, social and economic parallel to Ghana. South Africa is more developed but has

commonalities in that both have a severe shortage of radiologists and radiographers are

legally barred from producing reports.

Four common themes were identified from the retrieved articles: factors that influence the

introduction of role extension; accuracy of radiographer reporting; education and training

requirements; benefits of role extension/radiographer reporting. These themes are

discussed against the Ghanaian context and the conditions required for local

implementation of radiographer reporting considered.

6

Figure 1. Estimated number and distribution of radiologists throughout the administrative

regions in Ghana in 2014

No radiologists

Two visiting radiologists

No radiologists

One radiologist

No radiologists

One radiologist

Six radiologists

One radiologist

One radiologist

23 radiologists

7

Discussion

Factors likely to influence successful implementation of role extension

With many unreported radiographs and only 35 radiologists in 201432 the key generic

requirements for the implementation of radiographer reporting in Ghana are present. A

national survey to estimate the proportion of unreported radiographs would help define the

problem for service planners. Projection radiographs account for 54.6% of all imaging

studies in the UK.46 It can be assumed that this proportion is significantly higher in Ghana

given that there is national coverage of x-ray units, but just 12 MRI47 and 35 CT scanners.43

Two thirds of the scanners are located in the capital city Accra, with half the regions having

no MRI facilities.43,47 All regions that do have these modalities have resident radiologists

who ensure that all scans are reported on, even at some delay. Consequently, population

health benefit is most likely to be realised from concentrating initial role extension efforts

on the reporting of projection radiographs.

International literature reveals that perceived or real radiographer shortages are a live

concern when seeking how best to meet rising reporting demand: either through role

substitution from existing staff groups, or by establishing new roles.6,48 Current radiographer

numbers in Ghana (300) are already inadequate to address existing projection radiograph

demand.44 Fortunately, the workforce is set to expand significantly as the number of

universities offering a BSc radiography programme has increased from one to four.43

However, there will be a delay before the benefit of increased capacity is realised, so we

propose that implementing radiographer reporting in regions currently deficient in

radiologists is likely to have the greatest impact on patient outcomes, whilst maintaining

sufficient radiographers to supervise the new graduates. Radiologists’ enthusiasm, and the

effect of their pressure/enthusiasm on the radiographer’s professional behaviours, are then

crucial concerns in terms of the success of implementing radiographer reporting in Ghana.

There appears to have been some supportive radiologists in UK NHS trusts that championed

role extension in UK radiography.6 Despite successful collaboration between the UK College

of Radiographers and the Royal College of Radiologists (RCR), the latter has indicated that it

still does not believe non-medical reporting of radiographs is a solution to the radiology

crisis in Scotland.6,27 The GSR generally has an excellent working relationship with the Ghana

Association of Radiologists (GAR), but the local precedent of strong resistance from

8

radiologists towards radiographers performing ultrasound scans suggests the GSR should

anticipate similar challenges. This resistance to radiographers performing ultrasound scans

was seen to be expressed during stakeholder consultations. The GSR’s task will ultimately

have to present government with evidence that will convince them to amend the law, which

currently bars radiographers from providing written reports.

Part of the resistance to radiographer reporting expressed in the literature,6, 7, 15, 16, 27 is that,

as a profession, radiology has argued role extension would limit training opportunities for

junior radiologists.6 In Ghana, experienced radiographers may be considered to be an

appropriate resource for the teaching of junior radiologists, as already happens informally in

the absence of senior radiologists.

Similar to the transition to a radiography BSc degree in Ghana, the fact that the UK has

demonstrated a viable model for radiographer reporting provides the GSR with powerful

evidence for this initiative. A fundamental strand of evidence to this case is that vast areas

of Ghana still have no radiologists. Nigeria has a similar problem with 44.5% of hospitals

surveyed in Nigeria having no radiologists, only 33% had resident radiologists and 22.5%

relied on visiting radiologists.49 The closest evidence available, in terms of geography,

regarding radiologists’ attitudes comes from a 2009 survey of South African radiologists in

the Western Cape area, which reported that 68% supported role extension for

radiographers. Furthermore, many were willing to act supportively, for example assessing

clinical competence as well as acting as clinical mentors or supervisors as well as offering

academic support.50 These data give some further indication of the level of professional

support/resistance that may be expected from radiologists in Ghana.

Accuracy of reporting

There is a significant body of published evidence for the GSR to draw that supports the

proposition that suitably trained radiographers can perform reporting to the same

standards as radiologists in most areas of imaging.18, 51-58 International data demonstrates

that radiographers, following an accredited postgraduate programme delivered in a robust

academic environment, are capable of identifying abnormal chest radiographs and provide a

report on abnormal appearances to mean sensitivity and specificity scores of 95.4% (95% CI

94.4–96.3) and 95.9% (95% CI, 94.9–96.7), respectively.56 Radiographers can report on a

broad range of chest pathologies under controlled conditions and show high concordance

9

with consultant radiologists.56 Nigerian radiographers have been shown to be able to

interpret chest x-rays with mean sensitivity and specificity of 76.9% (95% CI, 65.8–86.4) and

79.8% (95% CI, 65.8–86.4), respectively.56 The negative disparity in sensitivity and specificity

between this study and UK data48 could be partly because the participants in this study had

not undergone formal training in radiograph reporting. Furthermore, the level of accuracy

was positively associated with the number of years in practice56 suggesting the segment of

the radiographer workforce to be targeted initially. Evidence of the ability of radiographers

to report musculoskeletal (MSK)18,51-53 CT and MRI across anatomical sites also supports the

potential for further role extension.57-59

Future radiography education requirements

Extended working requires education that is commensurate to meet the changing needs of

local practice.60 Extensive personal experience of rural and municipal radiography in Ghana

by the first author of the current paper provides anecdotal evidence that some

radiographers, particularly in rural areas, are already interpreting radiographs on an

informal basis, and thus working beyond their official scope of practice. This situation needs

to be formalised to ensure compliance with legal frameworks, prioritise patient safety and

protect individual practitioners. This would require an undertaking from internal and

external partners that radiographer reporting is underpinned by postgraduate level

education. This transition may be made more straightforward as Ghana prides itself on

using educational curricula similar to those used in the UK.

Some of the requisite clinical knowledge and teaching skills to enable postgraduate

programs in the clinical areas required by Ghana, such as radiographer reporting, may best

be provided from high knowledge settings in other countries/regions (either online or face-

to-face).61 Radiologists need to be involved, ideally in the development of programmes,

lecturing, examining and also, crucially, as mentors to radiographers. Clinical mentorship is

likely to be critical to the task of building reporting capacity in the face of staff shortages.62

Another early priority for HEIs will be to review the undergraduate curriculum to ensure

that image interpretation and clinical reporting are included at the foundation level.63 For

example, to start by preparing junior practitioners to provide preliminary comments on MSK

radiographs as a foundation for transition to full reporting.8

10

Whatever the exact mix of learning provision, advocacy for radiographer reporting is only

likely to be realised if it is spearheaded by the GSR in concert with HEIs.64 A key structural

development in progressing the education agenda is that the GSR (in association with other

allied health professions) are advocating for the establishment of a Ghana College of Allied

Health Professions. Crucially, a joint legislative instrument has been drafted by the

professional bodies with the support of the MoH to ensure that this college becomes a

reality.55 Once established, this college would be responsible for postgraduate education

and specialisation, with the overarching mission to improve patient care.

Potential to improve access to quality healthcare

International evidence demonstrates that radiographer role extension can contribute to

improved access to healthcare via reduced workload of radiologists, consequential shorter

waiting times for patients, and improved rates of reporting and accuracy of reports, as well

as increased job satisfaction for radiographers and, health service cost reduction.15-26

It is vital for the profession that the case for cost saving is not at the expense of patient

outcomes. International evidence suggests that morbidity has not increased with the

introduction of radiographer reporting of trauma MSK radiographs, although in some

instances there has been a reduction in the number of false negative diagnosis and

subsequent patient recalls.54 It can therefore be assumed that the strategic introduction of

radiographer reporting in Ghana could increase the proportion of reported radiographs and

hence improve clinical diagnosis and timely treatment interventions that have the potential

to reduce patient morbidity and mortality.

Evidence of cost reduction to hospitals through service redesign, role substitution and

reduced pay differentials8 is likely to be particularly important to policy makers in a

developing country. Ghana has many competing demands for extremely limited resources

and the case for radiographer reporting will be strengthened by drawing on such data-

driven arguments in alignment with professional drivers. The patient benefit would be

maximised if savings were redistributed within the GHS, for example to further improve

patient access via having more staff and equipment. Radiographer-led reporting in the

emergency department (ED) has already demonstrated cost effectiveness.65 That such a

chronic shortage of ED beds in Ghana results in some patients being turned away,

potentially leading to avoidable deaths,66 provides a compelling case for radiographer

11

reporting in this setting in order to reduce the waiting time for reports and so promote early

patient discharge.

Looking to the future

The Ghana MoH has already introduced a physician assistant program to help cater for areas

with an acute shortage of doctors.67 The GHS has also trained radiographers and midwives

in district hospitals to conduct obstetric ultrasound examinations for pregnant women.

These initiatives provide a clear exemplar to embolden the GSR lobby for radiographer

reporting in wider settings.

The formation of an Allied Health Professions Council (AHPC) as an independent regulatory

body can be a significant development in progressing the radiographer role extension

agenda.41 If basic level practice is not adequately regulated, then the challenges facing

extended practice are clear in a context where demonstrating competence will be crucial to

persuade radiologists to relinquish professional control on practices such as reporting. The

AHPC needs resources to effectively perform its task of regulation. Unfortunately, the MoH

has not, so far, seemed willing to provide these. If the AHPC digitised the registration

process it is likely more professionals would comply. The current situation where all

registrants have to travel to the capital Accra to register/renew their licenses acts as a

strong disincentive. Enforcement of registration would be promoted if the AHPC liaised with

the Health Facilities Regulatory Authority (HeFRA), which licences all healthcare facilities in

Ghana to ensure that their personnel are qualified to practice.

A functioning professional body (GSR), stronger regulatory body (AHPC) and new

educational body (Ghana College of Allied Health Professions) could work with radiologists

(GAR), the MoH and other influential stakeholders, including patient advocates, to develop a

deliverable policy on radiographer reporting (as a prime exemplar of extended working.) To

gain professional traction, the policy should be implemented via an agreed protocol that

would encompass basic elements such as educational requirements, scope of practice,

procedures for reporting, reporting structures and requirements for continuing professional

development.67

With appropriate postgraduate education focussed on radiographer reporting, there is

every reason to believe that Ghanaian radiographers would be able to perform to the same

12

standards as their counterparts in the UK. A baseline study to determine the current level of

competence in image interpretation under controlled conditions is now indicated, as well as

identifying image reporting skill/knowledge deficiencies to inform further training. Piloting

and evaluation of radiographer reporting initiatives, particularly in regions with low doctor-

to-population ratios, could help establish feasibility and would provide early data on

effectiveness. Such a staged, data-driven approach is more likely to persuade the MoH to

support policy that enables the introduction of locally responsive role extension.

Conclusions

Global drivers for role extension in diagnostic radiography include a shortage of radiologists,

increasing workload, technological advancements and shifting health policy. Although no

literature or empirical evidence was found on role extension in Ghana, differences in

professional structures and resources suggest that the wholesale adoption of existing

models may not always succeed in the Ghanaian context. Radiographer projection

radiograph reporting is the area of professional practice most aligned with local resources

and most likely to improve access to quality healthcare. Developments in professional

perceptions, education and regulation of reporting will all be required to establish

confidence in stakeholders. Evidence of economic and patient benefits through

contemporaneous research and audit should underpin strategic planning for further role

extension opportunities in Ghana and contribute to the case for radiographer role extension

in developing countries.

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